Category: Brief Report and Case Report

A mediastinal lymphoma detected by point-of-care ultrasound in a woman with worsening dyspnea. Hodgkin's Lymphoma: a case report

Maria Viviana Carlino3 MD, Alfonso Sforza1 MD, Andrea d’Amato2 MD, Antonio Pagano1 MD, Mario Guarino3 MD, Costantino Mancusi2 MD, Fiorella Paladino1 MD
1) Emergency Department, Cardarelli Hospital, Naples.
2) Hypertension Research Center, UOC Emergency Medicine, Federico II University Hospital, Naples.
3) Emergency Department, C.T.O., Naples.


A young woman presented to the Emergency Department with progressive dyspnoea. Point-of-care ultrasound, with pocket size device, was done upon arrival in Emergency Department. Thoracic ultrasound revealed a large left anterior mediastinal mass with significant left pleural effusion and left lower lobe atelectasis. Biopsy diagnosis was: Hodgkin's lymphoma.

Case Presentation

A 34-year-old woman presented to the Emergency Department (ED) with progressive dyspnoea. At the time of admission blood pressure was 120/70 mmHg, heart rate (HR) 70 bpm, regular, oxygen saturation was 95% (FiO2 21%) and respiratory rate was 22 breaths/min. Chest auscultation revealed abolished vesicular murmur at the left lung base. Cardiovascular examination revealed a normal cardiac rhythm, no murmurs, normal peripheral pulses and no oedema. The ECG showed sinus rhythm with normal AV conduction, normal axis and QT interval. Arterial blood gas analysis on room air revealed mild respiratory alkalosis with mild metabolic alkalosis, reduced partial pressure of oxygen (72 mm Hg), normal hemoglobin, electrolytes and lactate levels.
Results of blood tests showed a normal white blood cell count (7.600 cells per mm3), with renal and liver function test and serum electrolytes within the reference limits.
Point-of-care ultrasound (POCUS), with pocket size device, was done upon arrival in ED. Focused cardiac ultrasonography (FoCUS) showed normal left and right ventricular size and function. Thoracic ultrasound revealed a large left mediastinal mass (Figure 1, Video 1) with significant left pleural effusion and left lower lobe atelectasis (Figure 2, Video 2).
The patient underwent Contrast-enhanced CT scan of thorax that showed a large left anterior mediastinal mass (14.5x13.5x9.5 cm) suggestive of primary mediastinal lymphoma (Figure 3) and left significant pleural effusion with lingua and  lower lobe atelectasis.
Mass biopsy confirmed the diagnosis: Hodgkin's lymphoma (HL).


Hodgkin’s lymphoma is an uncommon B-cell lymphoid malignancy affecting 9,050 new patients annually and representing approximately 11.2% of all lymphomas in the United States (1). At the time of diagnosis, patients commonly present with cervical, anterior mediastinal, supraclavicular and axillary lymph node involvement (1). Pleural effusion is a common finding in HL, representing a negative prognostic factor (2).
Ultrasound can be used to guide biopsy of mediastinal masses and lymphnodes located in the anterior and upper mediastinum, these can be visualized using a suprasternal or parasternal approach (3).
We report a case of mediastinal Hodgkin's lymphoma manifested with dyspnea and detected by thoracic ultrasound, it represents a rare clinical entity described in literature.
This case is a timely reminder of the role that rapid evaluation by point-of-care ultrasound retains in the management of dyspnoeic patients, particularly when cases are complicated (4). Although the definite diagnosis is usually confirmed by other imaging modalities, it is convincible that point-of-care ultrasound is the first tool to detect anterior mediastinal mass in patients presenting to the ED for dyspnoea.
  1. Hodgkin lymphoma: 2016 update on diagnosis, risk-stratification, and management. SM., Ansell. Am J Hematol. 2016 Jun;91(4):434-42.
  2. Pleural effusions in patients with Hodgkin lymphoma: clinical predictors and associations with outcome. Hunter BD, Dhakal S, Voci S, Goldstein NP, Constine LS. Leuk Lymphoma. 2014 Aug;55(8):1822-6.
  3. Transthoracic US of the chest: clinical uses and applications. Koh DM, Burke S, Davies N, Padley SP. Radiographics. 2002 Jan-Feb;22(1):e1.
  4. Diagnostic performance of multi-organ ultrasound with pocket-sized device in the management of acute dyspnea. Sforza A, Mancusi C, Carlino MV, et al. Cardiovasc Ultrasound. 2017 Jun 19;15(1):16.
Figure 1. Thoracic ultrasound (Parasternal approach): detection of a large left anterior mediastinal mass
Figure 2. Point-of-care ultrasound: apical 4-chamber view and left pleural effusion associated with lung atelectasis. Legend. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; PE: pleural effusion; AL: lung atelectasis.
Figure 3. Contrast-enhanced CT scan: evidence of a large left anterior mediastinal mass.


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